Individual/Household

APPENDIX E

Child and Adult Care Food Program (CACFP)

Improper Payment Meal
Claims Assessment

(OMB No.: 0584-NEW)

Project Officer: Fred S. Lesnett

Office: Office of Research and Analysis

Food and Nutrition Service

Room 1014

3101 Park Center Drive

Alexandria, VA 22302

Telephone: 703-605-0811

Fax: 703-305-2576

E-mail: [email protected]

A

PPENDIX E:
PARENT-RECALL INTERVIEW

P

Public reporting burden for this collection of information is estimated to average 12 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: U.S. Department of Agriculture, Food and Nutrition Services, Office of Research and Analysis, Room 1014, Alexandria, VA 22302 ATTN: PRA (0584-xxxx*).  Do not return the completed form to this address.

CHILD AND ADULT FOOD CARE PROGRAM (CACFP) MEAL CLAIMS ASSESSMENT
ICF International

Attn: Erika Gordon, Project Director
11785 Beltsville Drive, Suite 300
Calverton, MD 20705
Tel: (800) 840-8248

arent Recall Interview Questionnaire

CACFP Meal Claims Assessment Parent Recall Interview Questionnaire

State ID:_________	Provider ID:_______________	Parent ID:________________
Sponsor ID:________________	Provider Name: _____________________	Sample ID:________________
		Replacement Parent/Child? Y/N
Date of Interview:_____/____/________		Reviewed by:________
Time: _____________ a.m./p.m.		HQAPVL:_______
Interviewer: _______________________________

[INSTRUCTION—IF ANSWERING MACHINE IS REACHED, LEAVE FOLLOWING MESSAGE]:

Hello, my name is ______________. I’m calling from ICF International, and our company is working with your day care provider, [NAME OF PROVIDER] and the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS) on a national study of the Child and Adult Care Food Program (CACFP). I would like to ask you a few questions about the meals your child receives while in the care of [NAME OF PROVIDER]. I will call you back again either later today or tomorrow to speak with you about this study. You may also return my phone call toll-free at 1-800-840-8248. Thank you. Have a nice day!

PART I: INFORMED CONSENT AND INTRODUCTION

[INSTRUCTION]: ______________. I’m calling from ICF International, and our company is working with your day care provider, [NAME OF PROVIDER] and the U.S. Department of Agriculture (USDA) Food and Nutrition Service (FNS) on a national study of the Child and Adult Care Food Program (CACFP). I would like to speak with the [PARENT OR GUARDIAN] OF [NAME OF CHILD] about the meals this child receives while in the care of [NAME OF PROVIDER]. This is for a study being conducted on the meals served at your child’s day care.

INT.1 Is this [NAME OF RESPONDENT]?

1. Yes [SKIP TO INT.3.]

2. No

INT.2 IF INT.1 = NO: Is [NAME OF RESPONDENT] available or can you tell me a good time to call back to reach [NAME OF RESPONDENT]?

BEST DAY/TIME TO CALL BACK: _______________

INT.3 The U.S. Department of Agriculture (USDA) is conducting a national study on meals served by day care providers who receive reimbursement from the Government for the food they provide to children who are in their care. This program is called the Child and Adult Care Food Program (CACFP), which you may know simply as the Food Program. Your day care provider [NAME OF PROVIDER] was randomly selected to participate in the study. As a part of the study, the USDA, the Federal agency that oversees the program, has asked ICF International, a professional research firm, to conduct a private survey of parents of children in day care about what meals are being served to the children. You have been randomly selected to participate in the survey from a list of parents/guardians with children currently enrolled in day care at [NAME OF PROVIDER]. The survey, which lasts 10–15 minutes on average, asks you questions about your child’s attendance and the meals he/she was served at day care during the last week specifically, Sunday, [DATE] through Saturday, [DATE]. Your provider, [NAME OF PROVIDER], received a notification letter from us about the study.

Your participation in the survey will have no effect on your provider’s agreement to serve meals through CACFP. The information that ICF International collects will not impact your child’s or daycare provider’s program participation or any benefits they may receive from the program. The information that we collect from you will be handled privately and will not be released with individual child, parent, day care provider, or sponsor identifiers outside this data collection, except as otherwise required by law. Participants in this study will be subject to assurances and safeguards as provided by the Privacy Act of 1974 (5 USC 552a), which requires the safeguarding of individuals against invasion of privacy. There are no risks to you if you participate in this survey; but if you feel uncomfortable with any of the questions, you may choose to skip them, or to stop the interview at any time. Although there are no direct benefits to you for participating in this survey, your participation will help us know what types of meals children are receiving in the Food Program.

INT.3A [INSTRUCTION]: May we continue?

1. Yes[GO TO INT. 4. IF IN DOUBT ABOUT LANGUAGE, ASK INT.3B.]

2. No[IF IN DOUBT ABOUT LANGUAGE, ASK INT.3B.]

INT.3B [INSTRUCTION—IF POSSIBLE LANGUAGE DIFFICULTIES, ASK]: May we continue in English?

1. Yes[GO TO ITEM 1NT.4.]

2. No[ASK: “What language do you speak?” AND RECORD ANSWER. IF THE QUESTION IS NOT UNDERSTOOD, ASK: “Español?” OR OTHER LIKELY LANGUAGE AND RECORD ANSWER. TELL THE RESPONDENT YOU WILL CALL BACK LATER.]

INT.3C [INSTRUCTION: INDICATE ON CALL SHEET THAT THE INTERVIEW NEEDS TO BE CONDUCTED IN ANOTHER LANGUAGE.]

 SPANISH

 OTHER: __________________________

INT.4 Do you have any [OTHER] questions about the survey at this time?

1. Yes

2. No

[INSTRUCTION: IF “YES,” ASK SPECIFIC QUESTIONS AND RESPOND PER FAQS, THEN REPEAT INT.4 UNTIL ANSWER IS “NO.”]

INT.5 Is now a convenient time for the interview?

1. Yes [GO TO SECTION A.]

2. No BEST DAY/TIME TO CALL BACK: _______________

3. Refusal [GO TO INT. 5A.]

INT.5A [REFUSALS]: This study plays an important role in ensuring that day care providers are serving the meals for which they are being reimbursed for. The U.S. Department of Agriculture (USDA) needs feedback from the parents of children who are in the program. Your name was randomly chosen—that is, selected by chance. Neither the USDA nor your day care provider will ever know your specific answers. Nothing you say will change the agreement you have to receive meals from the day care provider. Can we proceed with the few questions I have?

1. Yes

2. No—If now is inconvenient, we can schedule a different time. [PROBE: ADDRESS ANY CONCERNS RAISED.]

[INSTRUCTION: SEE IF RESPONDENT WILL DO INTERVIEW NOW.]

[INSTRUCTION: IF YES, GO BACK TO I.3; CHANGE TO YES, THEN CONTINUE.]

[INSTRUCTION: IF NO, SET CALLBACK SCHEDULE; IF ASSISTANCE NEEDED, RECORD NAME OF ASSISTANT FOR CALLBACK AND SET CALLBACK SCHEDULE.]

TIME ___________ DATE _____________

[IF RESPONDENT STILL REFUSES, THANK RESPONDENT AND TERMINATE INTERVIEW.]

FOLLOW-UP TELEPHONE CONTACT: PRE-SCHEDULED FOLLOW-UP INTERVIEW

FU.1 [INSTRUCTION]: Hello, may I speak to [RESPONDENT] _____________?

1. Yes [WHEN RESPONDENT IS REACHED, SAY]: Hi. This is _________, with ICF International. I spoke to you recently about the survey of the U.S. Department of Agriculture day care provider meal reimbursement program. You indicated that this would be a good time to talk.

2. No [GET TIME AND DATE WHEN RESPONDENT CAN MOST LIKELY BE REACHED. TERMINATE INTERVIEW.]

FU.2 [INSTRUCTION]: The U.S. Department of Agriculture (USDA) is conducting a national study on meals served by day care providers who receive reimbursement from the government for the food they provide children while in their care. This program is called the Child and Adult Care Food Program (CACFP), which you may know simply as the Food Program. Your day care provider [NAME OF PROVIDER] was randomly selected to participate in the study. As a part of the study, the federal agency that oversees the program, USDA has asked ICF International, a professional research firm, to conduct a private survey of parents of children in day care about what meals are being served to the child. You have been randomly selected to participate in the survey from a list of parents/guardians with children currently enrolled in day care at [NAME OF PROVIDER]. The survey, which lasts 10–15 minutes on average, asks you questions about your child’s attendance and the meals he/she was served at day care during the last week specifically, Sunday, [DATE] through Saturday, [DATE]. Your provider, [NAME OF PROVIDER], received a notification letter from us about the study.

Your participation in the survey will have no effect on your provider’s agreement to serve meals through CACFP. The information that ICF International collects will not impact your child’s or daycare provider’s program participation or any benefits they may receive from the program. The information that we collect from you will be handled privately and will not be released with individual child, parent, day care provider, or sponsor identifiers outside this data collection, except as otherwise required by law. Participants in this study will be subject to assurances and safeguards as provided by the Privacy Act of 1974 (5 USC 552a), which requires the safeguarding of individuals against invasion of privacy. There are no risks to you if you participate in this survey; but if you feel uncomfortable with any of the questions, you may choose to skip them, or to stop the interview at any time. Although there are no direct benefits to you for participating in this survey, your participation will help us know what types of meals children are receiving in the Food Program.

SECTION A. IDENTITY CONFIRMATION/DEMOGRAPHICS

A.1 Does your child, [NAME OF CHILD], currently attend [NAME OF FDCH]?

1. Yes[CONTINUE.]

2. No

[INSTRUCTION—IF NO]: When did (he/she) stop attending [NAME OF FDCH]?

_________ _____ __________

MONTH DAY YEAR

8. Don’t Know

9. Refusal

[INSTRUCTION: IF TARGET CHILD WAS IN DAY CARE HOME DURING THE TARGET WEEK, CONTINUE INTERVIEW. OTHERWISE, GO TO CLOSING; SECTION D, AND TERMINATE INTERVIEW.]

A.2 This survey asks detailed questions about the meals served to your child and your child’s attendance over the past week. Are you best able to answers questions of this type, or is there another parent/guardian who may be better informed about [NAME OF CHILD]’s day care arrangements? (For example, is there another parent/guardian who takes your child to and from day care and/or tracks the meals served to your child?)

1. Yes[CONTINUE.]

2. No

[INSTRUCTION—IF NO]: Is the [PARENT/GUARDIAN] available for this interview? [INSTRUCTION—IF YES]: [CONTINUE. IF NO, SET CALLBACK SCHEDULE. IF ASSISTANCE IS NEEDED, RECORD NAME OF THE ASSISTANT FOR CALLBACK AND SET CALLBACK SCHEDULE.]

8. Don’t Know

9. Refusal

A.3 When did [NAME OF CHILD] begin attending [NAME OF FDCH]?

PROBE: Was that in the beginning, middle, or the end of the month?

_________ _____ __________

MONTH DAY YEAR

1. Beginning of the month

2. Middle of the month

3. End of the month

4. Never attended

8. Don’t Know

9. Refusal

A.4 What is the age and grade level of your child?

1. Infant (11 months or younger)

2. Pre-schooler (1–5 years)

3. School-age (6+ years old)

4. Age:

5. Grade: (1 2 3 4 5 6)

9. Refusal

A.5 Is [NAME OF CHILD] your only child in this specific day care home?

1. Yes

2. No

[INSTRUCTION—IF NO]: How many other children besides [NAME OF CHILD] attend this specific day care home? _________

What are the names and ages of the other children who attend this same day care facility? [IF APPLICABLE, ASK CHILD’S GRADE LEVEL.]

1)

(First Name, Last Name) (Age) (Grade)

2)

(First Name, Last Name) (Age) (Grade)

3)

(First Name, Last Name) (Age) (Grade)

4)

(First Name, Last Name) (Age) (Grade)

A.6 Are you familiar with your enrollment agreement with your day care provider, which itemizes/states the meals that your child is being served on a daily basis?

1. Yes

2. No

8. Don’t Know

9. Refusal

We first want to confirm the meals [NAME OF CHILD] is scheduled to receive at day care on a regular basis.

A.7 How many days a week does (he/she) usually have a BREAKFAST at day care?

1. Does not eat breakfast at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.8 How many days a week does (he/she) usually have a MID-MORNING snack at day care?

1. Does not eat mid-morning snack at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.9 How many days a week does (he/she) usually have a LUNCH at day care?

1. Does not eat lunch at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.10 How many days a week does (he/she) usually have AFTERNOON SNACK at day care?

1. Does not eat afternoon snack at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.11 How many days a week does (he/she) usually have a SUPPER/DINNER at day care?

1. Does not eat supper/dinner at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.12 How many days a week does (he/she) usually have EVENING SNACK at day care?

1. Does not eat evening snack at day care

2. ____ Number of days

8. Don’t Know

9. Refusal

A.13 Does your child only receive meals prepared by the day care, or is he/she usually sent with food from home?

1. Child only gets meals from day care[GO TO SECTION B.]

2. Child only takes food from home

3. Child takes food from home and receives meal from day care (both)

8. Don’t Know

9. Refusal

A.14 What types of food items do you usually send your child to day care with?

1. Infant formula

2. Baby food (jars)

3. Finger foods/snacks

4. Prepared foods (Gerber Graduates, Chef Boyardee, Lunchables, etc.)

5. Cereal (breakfast-boxed cereals, etc.)

6. Rice cereal

7. Juices (juice boxes, etc.)

8. Milk

9. Sandwiches (deli meats, peanut butter and jelly, etc.)

10. Other (Specify): _____________________

SECTION B. DAYS AND HOURS OF ATTENDANCE AT DAY CARE DURING THE TARGET WEEK

[INSTRUCTION]: My next questions are about the DAYS and HOURS [NAME OF CHILD] attended day care at [NAME OF FDCH] last week from Sunday, [DATE] to Saturday, [DATE].

[INSTRUCTION: CODE MONTH/DAY OF THE WEEK; DATES FOR THE WEEK; USE SECOND ROW OF ARRIVAL/DEPATURE TIME PER DAY OF WEEK TO RECORD BEFORE AND AFTER-SCHOOL CARE HOURS IF APPLICABLE]

Did your child attend day care on—

B.1a. Sunday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YESWhat time did he/she arrive and leave day care on Sunday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
B.1b. Monday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YESWhat time did he/she arrive and leave day care on Monday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE: Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________
B.1c. Tuesday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YES  What time did he/she arrive and leave day care on Tuesday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________
B.1d. Wednesday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YES  What time did he/she arrive and leave day care on Wednesday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________
B.1e. Thursday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YES  What time did he/she arrive and leave day care on Thursday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________
B.1f. Friday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YES  What time did he/she arrive and leave day care on Sunday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________
B.1g. Saturday	1. Yes	2. No	8. Don’t Know	9. Refusal
B.2a If YES  What time did he/she arrive and leave day care on Sunday?	Arrival time (hour) _____________	Departure time (hour) _______________	8. Don’t Know	9. Refusal
	AFTERCARE Arrival time (hour) _____________	AFTERCARE Departure time (hour) _______________

SECTION C. MEALS SERVED DURING THE TARGET WEEK

[INSTRUCTION]: Next, I’d like to ask you about the specific meals and snacks your child was served by [NAME OF FDCH] each day during last week—that is, from Sunday, [DATE] to Saturday, [DATE]. Even if you indicated that your child doesn’t usually receive a meal or snack, I still need to ask what happened during the week of [DATE], as situations can change.

C.1 Did [NAME OF CHILD] get BREAKFAST at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.2.]

8. Don’t Know[GO TO C.2]

C.1A What days did [NAME OF CHILD] get BREAKFAST at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.2 Did [NAME OF CHILD] get MID-MORNING SNACK at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.3.]

8. Don’t Know[GO TO C.3.]

C.2A What days did [NAME OF CHILD] get MID-MORNING SNACK at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.3 Did [NAME OF CHILD] get LUNCH at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.4.]

8. Don’t Know[GO TO C.4.]

C.3A What days did [NAME OF CHILD] get LUNCH at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.4 Did [NAME OF CHILD] get an AFTERNOON SNACK at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.5.]

8. Don’t Know[GO TO C.5.]

C.4A What days did [NAME OF CHILD] get an AFTERNOON SNACK at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.5 Did [NAME OF CHILD] get SUPPER at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.6.]

8. Don’t Know[GO TO C.6.]

C.5A What days did [NAME OF CHILD] get SUPPER at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.6 Did [NAME OF CHILD] get an EVENING SNACK—served after supper—at [NAME OF FDCH] last week?

1. Yes

2. No[GO TO C.7.]

8. Don’t Know[GO TO C.7.]

C.6A What days did [NAME OF CHILD] get an EVENING SNACK at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.7 Did [NAME OF CHILD] get any other food served at the day care outside of the meals I have described at [NAME OF FDCH] last week?

1. Yes

2. No [GO TO C.8]

8. Don’t Know [GO TO C.8]

C.7A What days did [NAME OF CHILD] get other food served at day care outside of the meals I have described at [NAME OF FDCH] last week? [INSTRUCTION: ASK FOR EACH DAY THE CHILD ATTENDED.]

a. Sunday		1. Yes	2. No	8. Don’t Know	9. Refusal
b. Monday		1. Yes	2. No	8. Don’t Know	9. Refusal
c. Tuesday		1. Yes	2. No	8. Don’t Know	9. Refusal
d. Wednesday		1. Yes	2. No	8. Don’t Know	9. Refusal
e. Thursday		1. Yes	2. No	8. Don’t Know	9. Refusal
f. Friday		1. Yes	2. No	8. Don’t Know	9. Refusal
g. Saturday		1. Yes	2. No	8. Don’t Know	9. Refusal

C.8 Did [NAME OF CHILD] bring any food to day care from home last week [DATES] as a replacement for a meal?

1. Yes

2. No[GO TO C.9.]

8. Don’t Know

9. Refusal

C.8A [INSTRUCTION—IF YES]: Please tell me the days of the week and the meals the child took food from home for:

Day	Food item from home	Break­fast	Mid­morning snack	Lunch	After­noon snack	Supper	Evening snack
a. Sunday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
b. Monday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
c. Tuesday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
d. Wednesday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
e. Thursday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
f. Friday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No
g. Saturday	Other (Specify): ____________	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No	1.Yes 2. No

C.9 Did anything happen to [NAME OF CHILD] or to the day care provider last week that kept your child from receiving a meal at day care or impacted your child’s regular schedule for meals, for example a snow day, a child’s sickness, doctor’s appointment, an event at school, or the day care being closed unexpectedly?

1. Yes

2. No[GO TO SECTION D.]

8. Don’t Know

9. Refusal

C.9A [INSTRUCTION—IF YES]: Can you describe to me what happened last week that prevented [NAME OF CHILD] from receiving a meal at day care? Please tell me what specifically occurred and the date it occurred. [INSTRUCTION: RESPONDENT CAN PROVIDE EITHER THE DATE OR DAY OF THE WEEK; CODE DAY OF THE WEEK AS MM/DD/YY. EACH RESPONSE OPTION CAN HAVE MULTIPLE DATES. PROBE FOR MULTIPLE DATES.]

a. Child sickness	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
b. Scheduled child obligation (i.e., doctor’s appointment)	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
c. Family trip/obligation	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
d. Request for a special meal, as the menu served an option that the child didn’t like	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
e. Holiday (facility closed)	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
f. Other facility-closing event	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____
g. Other (Specify):__________________________________	Day(s) of the week: S M T W TH F S	Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____

C.10 Starting with the first day your child did not receive a meal last week because of [FILL IN FROM ABOVE], can you tell me which meal or meals [CHILD’S NAME] did not receive at day care because of the event?

1a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
2a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
3a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
4a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
5a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
6a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal
7a. Date (MM/DD/YY) to Date: ____/______/_____–____/______/_____ b. Day(s) of the week: S M T W TH F S	c. Activity: _____________________	d. 1. Breakfast 2. Mid-Morning Snack 3. Lunch 4. Afternoon Snack 5. Dinner 6. Evening Snack 7. All of the meals the child would have received on that day 8. Don’t Know 9. Refusal

SECTION D: CLOSING

[INSTRUCTION]: That’s the end of my questions. If you have any questions about the survey or the study FNS is conducting, please call the following toll-free number: 1-8XX-XXX-XXXX. Thank you very much for being a part of this study!

CACFP Meal Claiming OMB Package 0